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Our thoughts about Medicare audits & Medicare coverage criteria....

ZPIC audits? RAC audits? MAC audits? DOJ audits? OIG audits? MIC audits?  The proliferation of Medicare audits pose the largest financial and operational challenge to healthcare providers since the initiation of DRGs almost 30 years ago.  For providers that don't face this issue head on and embrace Medicare coverage criteria as the heart of their financial infrastructure - financial insolvency is a very, very real possiblity.

Over the past decade, CMS (the Centers for Medicare & Medicaid Services) has ramped up efforts to insure that healthcare providers are solely paid for services rendered that (1) meet requirements as originally established within the Social Security Act and subsequent regulations, (2) meet Medicare provider contractual obligations (Conditions of Participation) and (3) meet Medicare coverage criteria.

CMS is investing millions of dollars in dozens of separate – but coordinated – enforcement efforts to force providers to adhere to Medicare rules & regulations.  Unfortunately, while the vast majority of providers support the aggressive pursuit of fraud & abuse, a dynamic and ever-changing regulatory landscape makes it virtually impossible to insure 100% compliance with Medicare coverage criteria.

The modern CMS auditing effort is both far reaching and technologically advanced.  Coordinated efforts of law enforcement, Medicare Recovery Auditors, Medicare Administrative Contractors, Program Safeguard Contractors, Zone Program Integrity Contractors, Medicaid Integrity Contractors and a host of others are designed to crack down and eliminate fraud & abuse.

In addition to now having 1,000s of contracted individual auditors under the CMS umbrella, the government is utilizing leading-edge database technology and integrated business logic to assist in the day-to-day review of millions of electronic Medicare claims for payment.  Providers can no longer fly under the radar of the Medicare audit process.  If you submit electronic claims for payment, you are instantly being “audited” for the services rendered.

Top 5 Barriers to Medicare Compliance

Ok, let’s be honest. While the barriers to Medicare compliance are too numerous to address in the body of this discussion, the following would be generally considered as the TOP 5:

1)      First and foremost, the Medicare regulatory environment is so dynamic that even the most highly trained and skilled professionals struggle with day-to-day updates.  Decentralized and some times conflicting guidance from 100s of CMS contractors, continually changing regulations and disparate Medicare coverage criteria resources are just a few major problem areas.

2)     Providers nationwide are constantly pushed to make documentation, coding & billing decisions based upon an array of information and insight from sources other than CMS.  While these sources may provide an important advisory role they don’t have authority over Medicare payments.  Some of these include consultants, professional associations, commercial admission screening or “medical necessity” criteria, peers, lawyers, certification organizations, physician advisors and software vendors.

3)     Making changes isn’t nearly as easy as it sounds. With a 8 - 10% unemployment rate and potential fraud implications associated with Medicare billing practices, it can be very difficult to gain buy-in from key decision-makers.  No one wants to be the messenger when it can mean major repayments and reduced cash flow for the foreseeable future.

4)     The nation’s best attorneys, legitimate compliance consultants and Medicare audit defense professionals are advising clients to make every effort to adhere to Medicare coverage criteria.  However, arguing vague notions of “medical necessity” can be a boon for unscrupulous attorneys and consultants.  There are far too many consultants and other attorneys looking to tap into provider emotions and cash-in on provider retainers.

5)     Discussions and education of medical staff and senior management can be very stressful and is often avoided for political (or personal survival) reasons.

Sound simple?  It’s really not.  In order to “embrace” Medicare coverage criteria, you first have to know what it is.  In order to know what it is, you have to find it, evaluate it, understand it, synthesize it and then do something with it.  Oh yeah, you also have to convince everyone around you that it is the right thing to do and hope that the coverage criteria doesn’t change before you can get it implemented.

This is where Jackson Davis can help.  Whether it is completing mock Medicare audits, building and submitting Medicare appeals, assisting in revamping internal audit programs or providing compliance tools & education resources - Jackson Davis will be there for you.  For the past 25 years, no one has done a better job at assisting healthcare providers in enhancing day-to-day Medicare compliance and winning Medicare appeals.